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Pelvic Exams While Under Anesthesia Sparks Debate

As a medical student, Dr. Shawn Barnes
had an experience that he says left him feeling ashamed and conflicted.
During his rotation through the obstetrics and gynecology ward of a
teaching hospital in Hawaii, Barnes performed pelvic exams on women under anesthesia without the women's explicit consent to the procedure.

The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care.

However, to Barnes, the "implicit consent" patients gave when signing
the forms didn't ensure they understood exactly what happened while they
were unconscious â€” a relatively inexperienced medical student palpated
their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs.

"For three weeks, four to five times a day, I was asked to, and did,
perform pelvic examinations on anesthetized women," Barnes wrote in an
editorial published in the October issue of the journal Obstetrics and
Gynecology.

Teaching hospitals should stop this practice, Barnes told
MyHealthNewsDaily. Instead, patients should be asked to "explicitly
consent" to the procedure, meaning they specifically say they will allow
a medical student to conduct a pelvic exam.

Two doctors at a Boston hospital, writing in a counterpoint to Barnes'
editorial, say they agree that obtaining only implicit consent is
"morally unsound," but also say that this practice has largely faded
away. Guidelines from doctors' groups say that women should be fully
informed about the procedure, they noted.

"We have many providers who trained in other institutions, and in
conversation with them," it's clear that women are usually asked
specifically for their consent to a student-performed exam, said Dr.
Carey York-Best, an obstetrician and gynecologist at Massachusetts
General Hospital and one of the doctors who wrote the counterpoint to
Barnes' editorial.

But Barnes says the exams are done without explicit consent more often
than these doctors indicate. A 2003 survey of Philadelphia medical
students found that 90 percent reported being asked to perform pelvic
exams on women who had not explicitly consented to the procedure.

Both Barnes and York-Best said there are no recent data available on
exactly how many hospitals nationwide are not abiding by the guidelines
recommending that explicit consent be obtained.

In any case, Barnes said that guidelines do not govern real-world
practice â€” for this, laws are needed. During his residency, Barnes said
he raised his concerns regarding pelvic exams with his superiors, but
was told these exams were a long-standing, standard practice. "In fact, I
was told I was the first medical student or resident in institutional
memory to express concern over the practice," he wrote in his editorial.

York-Best said such laws would potentially overregulate doctors'
activities, and that the field is already far more regulated than many
others.

Why not just ask for permission?

Performing pelvic exams on anesthetized women just prior to surgery
provides medical students with a unique and valuable learning
experience, Barnes and York-Best both said. For one, muscles relax under
anesthesia, allowing the exam to proceed more easily and giving the
surgeon and medical student a clearer picture from which to plan the details of the surgery.

Additionally, women undergoing surgery have conditions that make their
anatomy abnormal. Most patients who come in for routine exams performed
by medical students don't have gynecological diseases, but medical
students need to be able to recognize and diagnose abnormalities. [5 Things Women Should Know About Ovarian Cancer]

In his editorial, Barnes presented the arguments he heard â€” from
attending physicians, residents, and other medical students, along with
published medical literature â€” that a woman's signature on a long form
was sufficient proof of her consent.

One argument is that such consent forms are simply the standard
practice, so the exams are not an issue. But the fact that professional
guidelines â€” from groups such as the American College of Obstetricians
and Gynecologists and the American Medical Association â€” say that
explicit consent is needed shows that this should not be the standard
practice, Barnes said.

Another argument he heard is that medical students don't ask for
specific permission to retract tissue or cut sutures during surgery, and
that the pelvic exam portion of the procedure is no different.

But Barnes argues that it is different. In fact, male medical students
must be chaperoned when performing pelvic exams on conscious patients,
but not when they remove surgical staples â€” this requirement reflects an
understanding on the part of medical practitioners a pelvic exam is a
more personal practice.

Do guidelines do enough, or are laws needed?

York-Best and her co-author, Dr. Jeffrey Ecker, suggest that the
physician responsible for the patient's care should ask the patient for
permission to allow a student to perform the exam, ideally well before
the surgery. Patients should also be given the opportunity to meet the medical student prior to the surgery, they write.

Most patients are willing to let the student do an examination when
asked by their own physicians, York-Best said, pointing to a 2009 study
in which 74 percent of patients consented to a student performing a
pelvic exam when they were asked by their doctor. In contrast, another
study found that 53 percent consented when they were asked by students.

"When it is a stranger, especially a nervous or awkward student, who
asks, they do not yet know if they can trust that person, and are likely
to err on the side of saying no," York-Best said.

It's important for doctors at teaching hospitals to advocate for the
teaching process in order to ensure that their students receive adequate
training, she said.

Barnes called this "a good idea," but maintained that laws are needed
to make sure that women understand what they are consenting to.

Hawaii is now one of four states (California, Illinois and Virginia are
the others) where doctors are legally required to obtain specific
consent for pelvic exams under anesthesia. The Hawaii law grew out of
Barnes' outreach to lawyers about the issue, and he testified before the
state legislature regarding the practice while the bill was under
consideration.

Pass it on: Medical students still perform pelvic exams on anesthetized women.e

My sons hospital is a teaching hospital, there are no signs, I dunno if you are being sarcastic or not? The only way I know is because we have met many students in his care and one of our former pedi's was a student under my sons former pulmunologist.

Quoting EireLass:

Alot of people don't go to teaching hospitals, because they want 'finished doctors' working on them, not students. They should read the sign that says 'teaching hospital'.

After I wrote it, I thought about my wording. I just moved here, and haven't had any medical care yet. But where I came from, there were 2 specific teaching hospitals. There wasn't a 'sign', but in all paperwork and brochures, it's told.

Quoting Mipsy:

My sons hospital is a teaching hospital, there are no signs, I dunno if you are being sarcastic or not? The only way I know is because we have met many students in his care and one of our former pedi's was a student under my sons former pulmunologist.

Quoting EireLass:

Alot of people don't go to teaching hospitals, because they want 'finished doctors' working on them, not students. They should read the sign that says 'teaching hospital'. They all signed paperwork stating they were allowing students to work on them.

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